Healthcare Provider Details

I. General information

NPI: 1639571607
Provider Name (Legal Business Name): SUNSET CHILDREN'S DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 SUNSET BLVD SUITE B
LEXINGTON SC
29072-7051
US

IV. Provider business mailing address

5080 SUNSET BLVD SUITE B
LEXINGTON SC
29072-7051
US

V. Phone/Fax

Practice location:
  • Phone: 803-807-2787
  • Fax:
Mailing address:
  • Phone: 803-807-2787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHI SAMPLE
Title or Position: DENTIST/ OWNER
Credential: DMD
Phone: 803-807-2787